Transcript Decision Support for Quality Improvement

Decision Support for Quality
Improvement
Unit 6.4: Tips for Successful
Clinical Decision Support Systems
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Objectives
• Investigate strategies for successful
design and implementation of decision
support systems
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Early Considerations
Primary
need and
target
area
• Efficiency improvement
• Early detection/accurate
diagnosis
• Evidence based treatment
• Prevention of adverse events
To whom • To whom information is delivered
and how • How information is delivered
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Early Considerations
User
control
• How much control user will
have in accessing and
responding to information?
Automatic:
Example: calendar alarm that is automatically presented to
remind user that a scheduled meeting is about to begin
On Demand:
Example: user can access the online thesaurus as needed
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5 Rights of CDSS
Right
Information
Right
Person
Right
Channel
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Right
Format
Right Time
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CDS Design
• More effective than manual decision support
processes
• CDS interventions most likely to be used:
– Fit into clinicians’ workflow
– Presented automatically
• If recommends actions for users to take: more
effective than if merely provides assessments
• If provides information at a time and place of
decision-making: more likely to have an impact.
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CDS Implementation
Workflow integration
• Includes structure or work system features
and processes that support care
• Step 1: Engage clinicians in design and
implementation
• Step 2: Analyze workflow and how CDS will
fit into that workflow
• Step 3: Determine need for process
improvement
• Step 4: Configure to meet users’ needs
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CDS Implementation
Data Entry and Output
• Most CDS are integrated into the EHR and
pull patient information from that record
• Some CDS are independent of the EHR and
the user may have to enter patient
information twice
• A consideration: who enters the data and
who receives the CDS advice?
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CDS Implementation
Standards and Transferability
• EHRs with CDS capability may not be ready
for use “off the shelf”
• Effective CDS implementation requires
some degree of local customization
• In the absence of standards for information
exchange of CDS, users will need to select
the rules and alerts that are most applicable
to their site
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CDS Implementation
Knowledge Maintenance
• It is difficult to maintain the accuracy of the
medical record (e.g., failure to update
medications or allergies)
• If information used to trigger the CDS is not
accurate, the alerts will not be accurate
• Knowledge imbedded in the CDS may be
out-dated (e.g. clinical practice guidelines
may change and the CDS will need to be
updated to reflect the current standard).
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Clinical Decision Support (CDS)
Inpatient Case Study
A semi-rural community hospital has bought a commercial
inpatient computerized order entry system (CPOE). The
hospital admits patients to its inpatient units from its
emergency department (ED) and from ambulatory clinics and
wants to assure and measure safe and timely admission and
transition of patients from the ED to the inpatient unit. The
hospital sees many cases of chest pain in the ED, which has
been identified as an area in which it can improve
management. There is a standard protocol for working up,
diagnosing, and treating patients with chest pain, and the
inpatient physician group would like to assure rapid initiation
of the protocol once the diagnosis of chest pain is made in
the ED.
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Inpatient CDS Case Study
Two Contingencies
A patient may come to the ED
with clear diagnosis of a major
event (heart attack) that requires
immediate transfer to the cardiac
intensive care unit (CICU). The
cardiac care team has specific
protocols for different cardiac
diagnoses that depend on rapid
evaluation and diagnosis in the
ED, timely communication to the
cardiac care team and
coordination of care (diagnostic
testing, interventions) and transfer
of the patient to the CICU.
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A patient may deteriorate acutely
after arrival to the ED.
Deterioration may be preceded by
changes in vital signs and
measures (e.g., heart rate,
respiratory rate, blood pressure,
oxygen saturation levels,
electrocardiogram) that are
tracked and recorded by patient
monitors with alarms for abnormal
values.
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Inpatient CDS Case Study
Considerations for Clinicians and IT
• What is CPOE and what are its functions in patient
safety?
• What is the role of CDS in CPOE?
• What is the sequence of events that must occur in
the average patient who presents to the ED with
chest pain and must be admitted to the inpatient
unit?
• What are the sequences of events for patients in
contingencies 1 & 2?
• What clinical data need to be monitored, detected,
and managed during the ED work-up of the
patient? Does this change for contingencies 1 & 2?
• What are the functions of CDS in data
management to ensure quality?
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Inpatient CDS Case Study
Considerations for Clinicians and IT
• Order sets
– How do order sets help assure safety and quality in
inpatient care?
– How are order sets created, implemented, and
maintained?
• Alerts and reminders
– How do alerts and reminders interact with users?
– How can alerts pose problems in patient safety?
• Access to drug dictionaries and patient data
– What are patient safety functions that CPOE/CDS
linked to patient data offer?
– What patient safety functions can drug dictionaries
offer to DCS and what challenges exist in
implementing them?
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Clinical Decision Support (CDS)
Ambulatory Care Case Study
Ambulatory practices in the community want to keep track
of patients who are admitted for chest pain (especially
those who are diagnosed with heart disease). They would
like to improve ongoing management of heart disease in
their population by being alerted to patient admission to the
hospital and hospital management and disposition of these
patients (new medications, management by specialists,
etc.). They have a good working relationship with the
hospital and some of the ambulatory practices affiliated
with the hospital already have a common electronic health
record that connects to the hospital information systems.
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Ambulatory Care CDS Case Study
Considerations for Clinicians and IT
• For practices with connected EHRs,
– What kinds of patient data need to be made
available to the ambulatory practices?
– What forms of CDS will be helpful to assure
continuity of care?
At the
hospital
• Information libraries
• Alerts and reminders
• Guidelines
At the
practices
• Information libraries
• Alerts and reminders
• Guidelines
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Ambulatory Care CDS Case Study
Considerations for Clinicians and IT
• For practices without connected EHRs,
– What are alternatives to implement CDS?
– What are challenges and barriers?
– What business strategies might be considered by
the hospital and the practices to improve EHR
adoption?
• If preventive care is to be the emphasis, how
can CDS be implemented in ambulatory EHRs
to improve prevention?
–
–
–
–
Information libraries for practitioners and patients
Evidence-based care guidelines
Alerts and reminders
Analysis tools for practice data
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Clinical Decision Support (CDS)
Public Health Case Study
The State Health Department has noticed the problem of
cardiac disease in community and wants to implement
programs to discover and intervene in both acute and
preventive care. It would like to establish health information
exchange (HIE) for cardiac care in the state. Public health
policy makers would like to have decision support that would
help improve cardiac care within the state. In meeting with
clinical cardiologists from community hospitals and a tertiary
university center in the state, public health officials are in
discussion with an IT team to improve the functionalities of
the local health information registries (primarily for
immunizations, infant metabolic screening, and cancer).
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Public Health CDS Case Study
Considerations for Clinicians and IT
• What is the public health information process for
cardiac health and who determines this?
– Surveillance: types of data reported, by whom, and
how often?
– Analysis: measures of importance?
– Response: public health responses?
• What data do public health officials need to assess
and make decisions about cardiac health in the
state?
– Access to information (institutional, regional, national)
– Guidelines
– Alerts and reminders (to public health officials, to the
public)
• What information standards are needed (clinical
data reporting, data reporting formats?)
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Summary
• When implementing CDS, IT professionals should
consider the primary need and target area, to
whom and how information is to be delivered, and
degree of user control.
• The 5 rights of CDS state that CDS should be
designed to provide the right information to the
right person in the right format through the right
channel at the right time.
• Important considerations are: workflow integration,
data entry and output, standards and
transferability, and knowledge maintenance.
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